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The Pharmacy Operations Analyst is responsible for primary contact for our providers to obtain authorization for retail pharmacy, home infusion and medical utilization management requests. These requests are received via fax, phone and web. In addition, the Pharmacy Operations Analyst supports inquiries from other business areas via phone and email.
Key Responsibilities:
- Receive, process, and archive provider's retail fax and phone authorization requests accurately using multiple computer systems against our Medical Policy Criteria
- Review and interpret member's eligibility, claim history, and Pharmacy Program information using the PBM claims software to provide information to both internal and external clients via telephone or email
- Analyze and interpret high level medical data and accurately data entry information according to NCQA guidelines
- Receive, process, and archive Home Infusion Therapy and Utilization Management Medical requests accurately using MCPS/Express Path and other systems via fax or telephone
- Communicate determinations to providers via incoming and outgoing telephone calls.
- Process pharmacy authorizations utilizing PBM real time on line claims adjudication software.
- Support new clinical program implementation
- Serve as a liaison to Member Services and other internal clients for real-time support on pharmacy benefit interpretation, Medical Policy interpretation, and plan design interpretation.
- Support Medicare Part D and understanding of CMS guidelines
- Other responsibilities as needed

Qualification (Knowledge, skills, and abilities):
- Excellent Customer Service skills
- Prior experience assisting members and/or providers with telephone inquiries
- Strong organizational, problem solving, communication, and interpersonal skills
- Excellent written and oral communication skills required.
- Must have strong data entry and attention to detail in building cases
- Must be able to multitask and be results oriented.

Education/Relevant Experience:
- Minimum of a High School diploma required. Associate or Bachelor's degree preferred.
- Proficiency in MCPS and Foundation 14 preferred
- Experience in a Windows environment preferred
- Previous experience in a managed care environment preferred
- Previous pharmacy experience preferred

LocationHinghamTime TypeFull time

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Blue Cross Blue Shield of Massachusetts is an Equal Employment / Affirmative Action Employer. Applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, veteran status, disability, sexual orientation, gender identity or expression, or any other characteristics protected by law.